General State of Readiness & How you can (& should) be Preparing for the Inevitable, Part 1 of 4
The message is, as always, begin to prepare now and begin making the changes to how you document now, so that you are better prepared as a provider for ICD-10 and so your coders and billers will have the information they need to take care of you and the patients properly.
The International Classification of Diseases system will be updated from the ICD-9 to the ICD-10 standard on October 1, 2013. These are the codes that are used in healthcare as a common language to describe the diagnosis, condition, or other reasons for a patient visit to the doctor or healthcare facility. Now around the world ICD-10 has been used for years, the United States is one of the last places to implement this coding.
Also around the world it is not such a “big deal” because it is only used for reporting and data collection. Because we (the United States) are also using the coding for provider and service reimbursement things have gotten and are much more complicated for us—hence the delay and extension in ICD-10 implementation. Yes, it is true that the impact will be a coding overhaul for your medical billers and coders. However, it is still going to have an affect the way you perform as a doctor also. To support the specificity needed for the new ICD-10 codes there will be new documentation requirements as well.
Now because of the coding your documentation will vary by the complexity of the patient situation, some will be short, sweet, and straight forwarding requiring minimal documentation because the code says it all. However, if the situation is more complex, more documentation will be needed to justify your code and more documentation will be needed to explain all of the details your coder and biller needs to figure out what codes are to use and bill out properly.
This isn’t just an ICD-10 problem, adjusting your documentation and increasing your staff training now will also pay you dividends now.
The message is, as always, begin to prepare now and begin making the changes to how you document now, so that you are better prepared as a provider for ICD-10 and so your coders and billers will have the information they need to take care of you and the patients properly. A coder cannot code what is not there. If information is not there, it does not exist and they cannot code for it. You can either document completely and correctly up front, or wage a back and forth battle with your coding and billing staff while they drag each piece of information out of you, hopefully before you forget it. Again, this isn’t just an ICD-10 problem, adjusting your documentation and increasing your staff training now will also pay you dividends now (oh, and you won’t have to suffer a negative audit later either).
- “Increased Documentation Requirements and ICD-10: What You Need To Know” by Peter Polack at Medical Practice Trends
- CMS/ICD10 Your official source for all things ICD-10 or 5010 related. Bookmark it! Love it! Use it!